Every finding on record at Apex Home Healthcare

During the Home Health Survey conducted March 15-17, 2021 Emergency Preparedness was reviewed at Apex Home Healthcare in Fleming Island, Florida and was in compliance per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

A recertification survey was completed on March 15-17, 2021 at Apex Home Healthcare. The facility was not in compliance with Code of Federal Regulations ( CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies. .

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on review of patient complaints and staff interviews, the agency failed to document resolution and follow up to patient complaints for 3 of 3 sampled patient complaints from a total sample of 13 patients (Patients #11, #12, #13). The findings include: Review of complaint for Patient #11, dated 9/22/20, revealed the patient called today to make a complaint regarding the Licensed Practical Nurse. He said the nurse was doing a terrible job wrapping his wound and she had not gotten the silver ointment in place correctly before applying the compression bandage, leaving the Velcro over the wound which caused it to bleed severely and be very painful. He said this was the second time it happened. He also complained that the nurse was always late and did not call. He also said at behest of his wife that there was $ 100.00 missing from the top of his dresser. He stated he did not see her in the bedroom, but his wife said he had fallen asleep while the nurse was still there. The patient was told that she would relay the information to the proper management and would reschedule the visit with another nurse. The intervention included notifying risk management, alternate staff member provided to client, and would discuss with clinician. There was no documented resolution or follow up with the patient. Review of complaint for Patient #12, dated 11/11/20, by her daughter revealed she was annoyed we were late starting her and wants Physical Therapy (PT). She said she took her mom out of the ALF because she was not getting PT, and she had been home since Monday and the nurse just came today. Her mom really needs PT. The staff person that accepted the call was the Occupational Therapist (OT). The OT documented that she told the daughter there was a process of getting things in order and said she would call PT and see if he can come earlier. There were no interventions, resolution or follow up with the complainant. Review of complaint Patient #13, dated 11/9/20, revealed the patient and his wife reported that the first nurse was not wearing a mask, and the second nurse had a mask but was touching his wound on his right toe without gloves. They reported they were not sure if the first nurse was wearing gloves, but they said the next nurse was not wearing gloves. They did not see hand sanitizing and washing. They did not see a blue barrier pad. They did not see any washing of instruments. They said they felt uncomfortable with the nurse who did not wear gloves. They said they were also worried about the nurse's cough who was wearing a mask and who touched his toe without gloves. The wife said she is going to post a sign on her door requesting that we all wear appropriate gear. Interview was conducted with the ED on 3/15/21 at 3:05pm. She was asked what was the process when a complaint was received. She said the clinician that receives the complaint documents in the flow system. When asked who was responsible for investigating the complaint, she said the clinician will try to resolve. If not, the complaint comes to her or the Clinical Director. She was asked who investigated the complaint for Patient #11. She said she received the call and documented. When asked what was the resolution, she said she spoke to the clinician about the missing money. She said she was never in the patient's room. When the patient was asked about the missing money, he had no issue and she said it was his wife and she was not home at the time. She was asked about the concerns regarding the dressing changes, and she said she assigned another nurse to the patient. She was asked where was the resolution and follow up documented, and she said there was no way to document in the system or if there was, she did not know how. Review of the agency's policy Grievance Procedure, Patient Complaints included: the agency will investigate complaints made by the patient, legal representative, caregiver and/or family to include but not limited to the following: treatment or care furnished inappropriately or inconsistently, mistreatment or neglect, abuse verbal, mental, sexual or physical, injuries of unknown source, misappropriation of patients property by anyone furnishing services on the behalf of the agency. The executive Director or Clinical Director interviews the patient, family and involved staff or other individuals and takes appropriate actions to resolve the issue. If ED, Regional Vice President, the Division President is notified for final resolution. After the investigation and analysis is completed but no later than 30 days after the complaint filed, the ED or CD will follow up with patient and complainant and document within the information system. .

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency failed to review medical records and medication profile for one patient (Patient #4) regarding drug allergies prior to documenting order for antibiotics for 1 of 13 sampled patients ( Patient # 4). The findings include: Record review for Patient #4 revealed 73-year old female with Start of Care (SOC) date 2/6/21, with diagnoses including diabetes type 2, bipolar disorder, hypertension, obesity, neuropathy, oxygen dependent. The Plan of Care (POC) included: Skilled Nurse (SN) 1wk1, 2wk1, 1wk3, 1 visit every 2 weeks, 1wk1. Physical Therapy (PT) 1wk1, effective 2/23 2wk4, Occupational Therapy (OT) 1wk1, 2wk4, Medical Social Worker (MSW) 1wk1, Home Health Aide (HHA) 2wk2. Review of the physician orders found new orders for Cipro 250 mg every 12 hours x 7 days for urinary tract infection (UTI), dated 3/15/21. Review of the SN notes revealed a visit was made on 3/15/21; however, no documentation was found regarding why patient was ordered an antibiotic. The assessment did not include if patient was experiencing signs/symptoms of urinary tract infection. Review of the medication profile and the POC revealed Patient #4 had an allergy to the antibiotic Cipro. There was no documentation the nurse that entered the order called the physician to clarify the order and ensure he was aware of a documented allergy. An interview was conducted with Executive Director (ED) on 3/16/21 at 4:10pm. She was asked if she was aware that Pt #4 had been ordered Cipro for a UTI, and the record revealed she had allergy to Cipro. She reviewed the order as she was not aware. She said the nurse should have reviewed the record and informed the physician regarding the allergy and document justification for the order. She stated she would call the nurse and find out if the physician was notified of the documented allergy. The SN returned her call and stated he would call the physician. On 3/17/21 at 10:05 am, the ED was asked if the SN had heard back from the physician regarding the Cipro, and she said not yet. At 3:25pm, the ED reported that the SN for Patient #4 had called and stated he spoke to the APRN and there was no allergy to the Cipro, it was more a sensitivity. The SN also reported he called to check on Patient #4 and ask if she had any symptoms of reaction. .

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the facility failed to notify the physician regarding services not provided for the medical social worker and home health aide for Patient #2, and failure to report Patient #2 had a documented allergy to antibiotic ordered for urinary tract infection for 1 of 13 sampled patients (Patient #2). The findings include: Record review for Patient #4 revealed 73-year old female with Start of Care (SOC) date 2/6/21, with diagnoses including diabetes type 2, bipolar disorder, hypertension, obesity, neuropathy, oxygen dependent. The Plan of Care (POC) included: Skilled Nurse (SN) 1 wk 1, 2 wk 1, 1 wk 3, 1 visit every 2 weeks, 1 wk 1. Physical Therapy (PT) 1 wk 1, effective 2/23 2 wk 4, Occupational Therapy (OT) 1 wk 1, 2 wk 4, Medical Social Worker (MSW) 1wk1, Home Health Aide (HHA) 2wk2. Review of the physician orders found a new order for Cipro 250 mg every 12 hours x 7 days for urinary tract infection (UTI), dated 3/15/21. Review of the SN notes revealed a visit was made on 3/15/21; however, no documentation was found regarding why patient was ordered an antibiotic. The assessment did not include if patient was experiencing signs/symptoms of urinary tract infection. Review of the medication profile and the POC revealed Patient #4 had allergy to the antibiotic Cipro. There was no documentation the nurse that entered the order called the physician to clarify the order and ensure he was aware of a documented allergy. An interview was conducted with Executive Director (ED) on 3/16/21 at 4:10pm. She was asked if she was aware that Pt #4 had been ordered Cipro for a UTI, and the record revealed she had allergy to Cipro. She reviewed the order as she was not aware. She said the nurse should have reviewed the record and informed the physician regarding the allergy and document justification for the order. She stated she would call the nurse and find out if the physician was notified of the documented allergy. The SN returned her call and stated he would call the physician. On 3/17/21 at 10:05 am, the ED was asked if the SN had heard back from the physician regarding the Cipro, she said not yet. At 3:25pm, the ED reported that the SN for Patient #4 had called and stated he spoke to the APRN and there was no allergy to the Cipro, it was more a sensitivity. The SN also reported he called to check on Patient #4 and ask if she had any symptoms of reaction. Review of the record revealed Patient #2 was ordered evaluation by MSW regarding home situation and possible placement in skilled nursing facility. There were no visit notes found for the MSW. An interview was conducted with ED on 3/16/21 at 10:30 am. She was asked if Patient #2 had been seen by the MSW per the plan of care. She said the MSW notified her on 2/18/21 that she had not been able to reach the patient on the phone. The MSW said that she called the patient every day that week and she did not answer the phone. The MSW stated she would notify the physician and have the order discontinued. When asked if Patient #2 was receiving any other services from the agency, she said SN, PT, and OT. She was asked if the other clinicians had difficulty reaching the patient, and she said "no"; however, the patient often refused visits or changed her days. When asked if the MSW had contacted the physician to discontinue the order, she said she told her to call. However, after review of the record, she said MSW did not make the call. The ED was asked if the MSW had made any further attempts, she said "no". The ED said she would notify the physician. Review of the calendar found no visits were found scheduled for HHA services. Review of the record found no HHA notes or care plan. An interview was conducted with ED on 3/16/21 at 3:10pm. She was asked why there were no HHA visits scheduled on the calendar, and she said the agency has not had a HHA in a year. She was asked why were orders accepted for HHA if one is not available, and she said if the patient needs assist with Activities of Daily Living, OT provides bathing/showers or the LPN. She was asked if OT or the LPN had provided bathing or showers. She was asked how were the clinicians made aware that bathing/shower was to be provided, nd she said it would be on their assignment. She was asked if OT or the LPN had been assigned to bathe patient and if so, when did that occur. She reviewed the record and stated there was no documentation showers had been provided. She was asked if the provider that ordered the home health aides was notified that the service was not available and service not provided, she said "no." .

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency failed to coordinate care and services to provide Medical Social Worker and Home Health Aide for 1 of 13 sampled patients (Patient #2) The findings include: Record review for Patient #4 revealed 73-year old female with Start of Care (SOC) date 2/6/21, with diagnoses including diabetes type 2, bipolar disorder, hypertension, obesity, neuropathy, oxygen dependent. The Plan of Care (POC) included: Skilled Nurse (SN) 1 wk 1, 2 wk 1, 1 wk 3, 1 visit every 2 weeks, 1 wk 1. Physical Therapy (PT) 1 wk 1, effective 2/23 2 wk 4, Occupational Therapy (OT) 1 wk 1, 2 wk 4, Medical Social Worker (MSW) 1wk1, Home Health Aide (HHA) 2wk2. Review of the record revealed Patient #2 was ordered an evaluation by MSW regarding home situation and possible placement in skilled nursing facility. There was no visit notes found for MSW. An interview was conducted with ED on 3/16/21 at 10:30 am. She was asked if Patient #2 had been seen by the MSW per the plan of care. She said the MSW notified her on 2/18/21 that she had not been able to reach the patient on the phone. The MSW said that she called the patient every day that week and she did not answer the phone. The MSW stated she would notify the physician and have the order discontinued. When asked if Patient #2 was receiving any other services from the agency, she said, SN, PT, and OT. She was asked if the other clinicians had difficulty reaching the patient, she said "no"; however, the patient often refused visits or changed her days. When asked if MSW had contacted the physician to discontinue the order, she said she told her to call. However, review of the record, she said MSW did not make the call. The ED was asked if the MSW had made any further attempts, she said "no". The ED said she would notify the physician. Review of the calendar found no visits were found scheduled for HHA services. Review of the record found no HHA notes or care plan. An interview was conducted with ED on 3/16/21 at 3:10pm. She was asked why there were no HHA visits scheduled on calendar. She said the agency has not had an HHA in a year. She was asked why were orders accepted for HHA if one is not available. She said if the patient needs assist with activities of daily living, OT will provide bathing/showers or the LPN. She was asked if OT or the LPN had provided bathing or showers. She was asked how were the clinicians made aware that bathing/showers were to be provided, and she said it would be on their assignment. She was asked if OT or the LPN had been assigned to bathe patient and if so, when did that occur. She reviewed the record and stated there was no documentation showers had been provided. She was asked if the provider that ordered the home health aides was notified that the service was not available and service not provided, she said "no". .

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on agency record reviews and staff interviews, the agency failed to maintain a coordinated agency-wide Quality Assurance Performance Improvement (QAPI) program to measure and analyze quality indicators to improve health outcomes. Patient safety and quality of care has the potential to affect all patients. There were only 2 of 4 documented quarterly meetings. The findings include: Record review of the agency's QAPI program for the past twelve months found that there were committee meeting documentation for two out of four quarterly QAPI meetings. The agency was unable to produce any documents for quarterly QAPI meeting for November 2020 and February 2021. The documents they were able to produce for the remaining quarters were dated June 4, 2020 (Administrator stated this was for 1st quarter 2020), and August 20, 2020 (Administrator stated this was for 2nd quarter 2020). An interview was conducted with the Administrator on 3/17/2021 at 10:00am. During the interview, she was asked if the agency had a QAPI committee and if so, who attended. She stated 'yes', and the QAPI committee consisted of herself, her Director of Nursing, and her clinical staff. She was not specific as to which clinician staff were part of the QAPI program, but stated they help the QAPI during staff meetings. She was then asked if the agency had quarterly QAPI meetings in 2020 as outlined in the agency's policy and procedure. She stated they had, but she only had documentation to show two out of four of those meeting occurred. She stated she knows she had a QAPI meeting in November, but hadn't typed up the minutes. She could not recall the date in November that the QAPI meeting was held. She did not have any hand written minutes to show. She stated their 4th quarter 2020 meeting was held on February 25, 2021, but she hadn't typed up those minutes. She didn't have any handwritten minutes to show. Review of agency's policy titled "QAPI- Quality Assessment Performance and Improvement Program" (effective date 4/1/99, revised 8/4/05, 11/15/08, 3/1/09, 12/1/13, 1/1/18, 4/1/19, and 9/1/20) states: 5. Executive Responsibilities: The agency Executive Director assures the overall implementation of the program and regularly reports activities and findings to the governing body, at least once quarterly, and documents in the meeting minutes. .

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency failed to conduct and document performance improvement projects to improve quality of services provided with the potential to affect all patients. The findings include: Record review of the agency's Quality Improvement Performance Improvement (QAPI) program for the past 12 months found there were no performance improvement projects (PIP) conducted. Review of the committee meeting minutes for the past 12 months found no documentation that any new issues were discussed or identified. An interview was conducted with the Administrator on 3/17/2021 at 10:00am. During the interview, she was asked if the agency had conducted any performance improvement projects (PIP). Her documentation showed one PIP concerning re-hospitalization rate, which had identical information input on the QAPI meeting minutes on June 4, 2020 (which she identified as the first quarter QAPI meeting for 2020), and on the QAPI meeting minutes on August 20, 2020 (which she identified as the second quarter QAPI meeting for 2020). She was unable to produce any documentation for any PIP to show any measurable progress was achieved. Review of the agency's policy titled "QAPI- Quality Assessment Performance and Improvement Program" (effective date 4/1/99, revised 8/4/05, 11/15/08, 3/1/09, 12/1/13, 1/1/18, 4/1/19, and 9/1/20) states: Purpose: To develop, implement, and maintain an effective, on-going, agency wide driven quality assessment performance improvement program that reflects the complexity of the organization and the services it provides. 4. Performance Improvement Projects: Documentation of the QAPI programs includes: a. all performance improvement projects being conducted; b. the reasons for conducting these projects; c. measurable progress achieved during the performance improvement projects; d. evidence that demonstrates the operation of the home health's QAPI program. .

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and staff interviews, the agency failed to ensure nursing documentation reflected current condition for 1 of 13 sampled patients (Patient #2). The findings include: Review of the record for Patient #2 revealed Skilled Nurse (SN) documented a new order for antibiotic (Cipro) for urinary tract infection (UTI) on 3/15/21. There was no documentation regarding when the UTI was identified, what signs and symptoms were present, if lab tests were ordered to confirm, or follow up documentation after identified and treated. The SN made a visit on 3/2/21, with no documentation of signs or symptoms of UTI. There was a missed visit on 3/12/21. The next SN visit was made on 3/15/21 and documented a new order for antibiotic; however, no documentation of when symptoms presented or for how long. An interview was conducted with the Executive Director (ED) on 3/17/21 at 3:30 pm. She was asked where did the nurses document change of condition or new onset of infection. She said in the SN notes. She was asked if the SN notes on 3/15/21 for Patient #2 indicated new onset of urinary tract infection. After review of the record, she said she did not find any. She said the SN should have documented not only a new antibiotic was ordered but what symptoms were present, how long, if she was seen by physician, and any labs or urine tests ordered. .